Summary

Abusive head trauma refers to the constellation of cranial, spinal cord, and brain injuries which result from inflicted injury in infants and young children.

Diagnosis generally rests on the finding of unexplained injury to the skull, brain, and/or spinal cord in an infant who has no other medical explanation for their clinical presentation.

Frequently, there are other associated findings such as widespread retinal hemorrhaging, unexplained bruising, fractures and/or abdominal trauma. These additional findings are not necessary to make the diagnosis of abusive head trauma.

The clinical presentation and degree of injury occur on a spectrum from mild to severe.

Around 16% to 38% of victims die from their injuries.

Most surviving victims are at high risk of permanent neurologic damage, vision loss, and pervasive cognitive deficits and behavioral issues ranging from moderate to severe.

Children with inflicted brain injury have worse neurocognitive outcome than those with accidental head trauma.

In many cases repeated injury has occurred, as documented by the finding of old injuries such as fractures and previous head injury.

Definition

"Shaken baby syndrome" is the lay term used to describe the constellation of injuries resulting from violent shaking of an infant by an adult or adolescent. This injury is better classified as abusive head trauma, which is described by the American Academy of Pediatrics as a serious and common form of child abuse.
[1]Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009 May;123(5):1409-11.
http://pediatrics.aappublications.org/cgi/content/full/123/5/1409
http://www.ncbi.nlm.nih.gov/pubmed/19403508?tool=bestpractice.com
Abusive head trauma includes not only shaking, but direct trauma to the head, which may occur when a child is thrown or slammed against a surface. With shaking, the resultant rotational and repetitive force can lead to a spectrum of injuries, ranging from mild to fatal, and may cause subdural hemorrhage, retinal hemorrhage, and brain injury from contact injuries and hypoxic/ischemic injury cascades. In most cases, there is also blunt force trauma. The forces that result from blunt force trauma (described as an acceleration-deceleration injury) are much higher than forces from shaking alone; thus some clinicians feel that in children with severe brain injury there has likely been not only shaking but direct head trauma. Abusive head trauma may be associated with other forms of physical abuse that may result in bruising, fractures, or abdominal injury in addition to brain injury.
[2]Duhaime AC, Christian CW, Rorke LB, et al. Nonaccidental head injury in infants - the "shaken-baby syndrome." N Engl J Med. 1998 Jun 18;338(25):1822-9.
http://www.ncbi.nlm.nih.gov/pubmed/9632450?tool=bestpractice.com
[1]Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009 May;123(5):1409-11.
http://pediatrics.aappublications.org/cgi/content/full/123/5/1409
http://www.ncbi.nlm.nih.gov/pubmed/19403508?tool=bestpractice.com
[3]Sieswerda-Hoogendoorn T, Bilo RA, van Duurling LL, et al. Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse. Acta Paediatr. 2013 Nov;102(11):e497-501.
http://www.ncbi.nlm.nih.gov/pubmed/23909838?tool=bestpractice.com

Disclosures

Dr Barney Scholefield would like to gratefully acknowledge Dr Joe Brierley, Dr Gavin Wooldridge, and Dr Alice Newton, previous contributors to this monograph. JB, GW, and AN declare that they have no competing interests.